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  • National Health Emergency Triggers CMS Waivers for Medicare, Medicaid, CHIP

    The "blanket waiver" system now in effect eases a wide range of requirements, but CMS still won't reimburse for telehealth by PTs.

    President Donald Trump's declaration of a national emergency in response to the coronavirus pandemic has resulted in enactment by the Centers for Medicare and Medicaid Services of special waiver provisions that affect a broad range of activities and settings in Medicare, Medicaid, and the Children's Health Insurance Program, or CHIP. The so-called "1135 waivers" — a reference to section 1135 of the Social Security Act — are being offered temporarily to clinicians and facilities.

    CMS has issued a special edition of MLN Matters covering the 1135 waivers. Here are some important elements of the process you need to understand.

    These are "blanket waivers" that automatically authorize providers to take advantage of the changes — but CMS wants you to notify your survey agency and CMS regional office before you do.
    The waivers are available immediately and cover everything from general payment policies to admission requirements for facilities. CMS offers a fact sheet on the waivers available; if you believe a specific waiver would be helpful, contact your state survey agency as well as your CMS Regional Office.

    • ROATLHSQ@cms.hhs.gov (Atlanta RO): Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee
    • RODALDSC@cms.hhs.gov (Dallas RO): Arkansas, Louisiana, New Mexico, Oklahoma, and Texas
    • ROPHIDSC@cms.hhs.gov (Northeast Consortium): Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West Virginia, New York, New Jersey, Puerto Rico, Virgin Islands, Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont
    • ROCHISC@cms.hhs.gov (Midwest Consortium): Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin, Iowa, Kansas, Missouri, and Nebraska
    • ROSFOSO@cms.hhs.gov (Western Consortium): Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming, Alaska, Idaho, Oregon, Washington, Arizona, California, Hawaii, Nevada, and the Pacific Territories

    CMS also offers instructions on how to make a waiver request.

    The waivers don't affect state laws or regulations, or change the services reimbursed—or not reimbursed—by CMS. That means PTs still can't be reimbursed for telehealth.
    Services that weren't covered before the 1135 system was put in place still aren't covered. Even though recently passed legislation eased some Medicare telehealth restrictions, the changes didn't expand the list of health care professionals who can furnish telehealth—and PTs aren't on that list. Medicare Advantage plans have some flexibility when it comes to telehealth, but it’s up to the plan to just how flexible they want to be.

    HIPAA is still in effect.
    The HIPAA Privacy Rule, the HIPAA Security Rule, and the confidentiality provisions of the Patient Safety Rule aren't eased, but during the national emergency, HHS may waive sanctions against a covered hospital that does not comply with certain HIPAA provisions. In other words, when it comes to HIPAA, nothing has changed. The HHS Office for Civil Rights has produced a bulletin on the waivers as they related to HIPAA; additionally, OCR offers a webpage on how HIPAA rules apply in an emergency, and a "HIPAA Disclosures for Emergency Preparedness Decision Tool."

    The 1135 provisions include a "waiver of provider licensure," but it doesn't mean much unless a state creates a waiver, too.
    The 1135 system wasn't created solely for pandemics — it's also used to respond to regional disasters, where out-of-state providers may be needed to respond to an emergency. That's where the licensure waiver has the most effect. While the provisions do include a waiver that allows authorized providers to render services outside their states of Medicare enrollment, in order for the provider license waiver to be of much practical use, states would need to create their own licensure waivers — otherwise, the state requirements win out.

    Provider enrollment requirements have been eased.
    CMS has issued a blanket waiver of certain Medicare enrollment requirements, including application fees, fingerprint-based criminal background checks, and site visits. CMS has also postponed all revalidation actions. Additionally, CMS will establish a toll-free hotline PTs and other providers can use to enroll and receive temporary Medicare billing privileges, and the agency will expedite any new or pending enrollment applications.

    Facility surveys are being prioritized — but not eliminated.
    The waiver process doesn't end surveys, but CMS has prioritized the kinds of surveys that will be done, in coordination with state and local health departments, accrediting bodies, and the CDC. Effective immediately, survey activity is limited to the following (in priority order):

    • All immediate jeopardy complaints (cases that represent a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk) and allegations of abuse and neglect
    • Complaints alleging infection control concerns, including facilities with potential COVID-19 or other respiratory illnesses
    • Statutorily required recertification surveys (nursing home, home health, hospice, and intermediate care facilities) for individuals with intellectual disabilities
    • Any re-visits necessary to resolve current enforcement actions
    • Initial certifications
    • Surveys of hospitals and other facilities that have a history of infection control deficiencies at the immediate jeopardy level in the last three years
    • Surveys of hospitals, dialysis centers, and other facilities that have a history of infection control deficiencies at lower levels than immediate jeopardy

    Available waivers also include eased requirements for critical-access hospitals, long-term care hospitals, and inpatient rehabilitation facilities, but those facilities still need to notify the state survey agency and CMS Regional Office.
    Bed limits, length-of-stay requirements, the IRF "60 percent rule" governing discharges, and other provisions can be eased under the waiver system, but just like individual clinicians, facilities must notify CMS of the waivers it will be implementing.

    It's up to individual states to request waivers related to Medicaid and CHIP.
    Unlike waivers available in Medicare, there is no specific form or format required to submit the request for a Section 1135 waiver under Medicaid, but states are being advised to clearly state the scope and impact of the issue. States and territories may submit a Section 1135 waiver request directly to the CMS Acting Director, Medicaid & CHIP Operations Group Center for Medicaid & CHIP Services. The types of relief that state Medicaid agencies can seek are outlined in the CMS fact sheet.

    There are additional resources worth checking out.
    In addition to a fact sheet on the blanket waivers, CMS offers a detailed set of common questions and answers related to the 1135 system, and a "waiver at a glance" document that takes a more big-picture approach.

    Visit APTA's Coronavirus webpage for information and updates.

    PTAs Will be Authorized TRICARE Providers Beginning Mid-April

    In a win for PTAs and OTAs, the Department of Defense has issued a final rule, effective April 16, that establishes them as providers in ways similar to Medicare provisions.

    In this review: TRICARE; Addition of Physical Therapist Assistants and Occupational Therapy Assistants as TRICARE-Authorized Providers (final rule)
    Effective date: April 16, 2020

    The Big Picture
    A big win is finally (nearly) here: The Department of Defense has issued a final rule that establishes PTAs and OTAs as authorized providers under TRICARE, the health insurance system used throughout the military. The rule, set to take effect on April 16, largely follows the PTA approach used by CMS, and includes requirements related to supervision, the reach of state and local law, and the scope of allowable PTA activities. The inclusion of PTAs in TRICARE was a major advocacy focus for APTA. DoD estimates that the cost of increased utilization, along with a first-year implementation cost of $350,000, will be $20 million over five years.

    Also Notable in the Final Rule

    • Qualification and supervision requirements for the most part mirror Medicare provisions for PTAs and OTAs.
    • Direct supervision will be required in the private practice setting, with the supervising PT required to be in the office suite where the PTA is working and immediately available to provide assistance and direction — but not required to be in the room with the PTA while the procedure is being performed.
    • Outside of private practice, the rule calls for "general supervision" that does not require the PT’s presence during the PTA's performance of the procedure. The supervising PT will have continuing responsibility for training the PTA.
    • Where state or local supervision laws are more stringent, PTs and PTAs will be required to follow those laws.
    • Physical therapy aides will not be covered, even if working under the supervision of a TRICARE authorized PTA or PT.
    • DoD adopted APTA's recommendation to change its terminology and is now using the term "physical therapist assistants" in reference to the PTA, abandoning its use of "physical therapy assistants."

    "Although we've known that this change would be happening since 2017, we're pleased that DoD issued the final rule slightly ahead of schedule, and with virtually all of the suggestions provided by APTA," said Kara Gainer, APTA's director or regulatory affairs. "PTAs are crucial members of the service delivery team, and their inclusion in TRICARE will significantly improve patient access to effective, needed care."

    Telehealth in Physical Therapy in Light of COVID-19


    [NOTE: No updates will be made to this article after April 16, 2020. Updated information can be found at this dedicated webpage.]



     The coronavirus pandemic demands that health care providers rethink how they deliver care in ways that reduce risk of further spreading infection.(Note: this article is also presented as a recorded webinar and accompanying slides).

    The use of telehealth is one approach that can help keep both patients and providers safe, but PTs and PTAs need to understand the current regulatory and payer telehealth landscape to decide whether telehealth is right — or even a possibility — for them.

    The information below can help you get a better sense of the issues surrounding physical therapy and telehealth, particularly related to the current viral outbreak. Keep in mind that circumstances are constantly changing and this information is current as of the publication date.

    In General

    • We recently updated our resources on telehealth related to areas such as legislation and regulation, risk management considerations, billing and coding considerations, and implementing telehealth in practice. You will find these on the APTA Telehealth webpage.
    • We also published a blog post, "Challenges and Opportunities in Telehealth: a Q&A."
    • We have received several questions related to Congress' coronavirus legislation signed into law last week. It gives the Department of Health and Human Services authority to waive certain Medicare telehealth restrictions (with stipulations) and continues to limit provider types who can furnish telehealth to Medicare beneficiaries. Physical therapists are not included as a provider type that can furnish telehealth as a covered service to Medicare beneficiaries under this legislation. Due to a number of questions related to this legislation, APTA issued a March 9 news advisory on telehealth.
    • A CMS fact sheet describes regulatory flexibilities and other actions the agency implemented in March to help health care providers and states respond to and contain COVID-19. The actions did not include expanding Medicare coverage to include telehealth services furnished by physical therapists. The actions did include temporarily waiving Medicare and Medicaid requirements that out-of-state providers hold licenses in the state where they are providing services. The requirement is waived as long as the provider has an equivalent license from another state — but keep in mind this does not waive state or local licensure requirements. Also, the waiver does not allow for payment for otherwise non-covered services — such as telehealth services provided by physical therapists.
    • In addition, the Center for Connected Health Encounters offers "Billing for Telehealth Encounters: An Introductory Guide on Fee-for-Service (.pdf)," a 21-page document that outlines billing procedures.
    • Note that other terms, such as telerehabilitation, telerehab, telemedicine, and telepractice are being used by various entities. They all can refer to use by PTs and PTAs; this article generally uses "telehealth."

    Practice via Telehealth

    Regardless of the payer or policy, PTs and PTAs must ensure that when providing telehealth services or billing for them, they are practicing legally and ethically, and are adhering to state and federal practice guidelines and payer contract agreements. You review and understand your state's practice act regarding the delivery of physical therapist services via telehealth.

    Per APTA's ethics documents (www.apta.org/Ethics/), we recommend that physical therapists use their discretion as to the nature and frequency of using telehealth, and do so within their scope of practice while abiding by any state practice act restrictions as well as their obligations to the physical therapy profession.

    Although telehealth is not specifically codified within the APTA "Code of Ethics for the Physical Therapist" or the "Standards of Ethical Conduct for the Physical Therapist Assistant," the entirety of the code applies to telehealth services delivered by PTs and PTAs. Ethical practice in telehealth must account for the biological, social, psychological, and cultural needs of the patient while working to improve their health. Additionally, knowing when to urge and how to persuade the patient to seek a face-to-face level of care is key. Before providing telehealth, ensure that you meet all local, state, and federal laws and regulations. To achieve the potential for patient benefit, you must consider the associated ethical issues; specifically, carefully assess the effect on relations between clinicians, patients and clients, and their families and/or caregivers.

    Telehealth provision or use does not alter a covered entity's obligations under HIPAA, nor does HIPAA contain any special section devoted to telehealth. Therefore, if a covered entity is utilizing telehealth that involves PHI, the entity must meet the same HIPAA requirements that it would if the service was provided in-person.

    The House of Delegates position on telehealth (.pdf), last updated in 2019, recognizes telehealth as a well‐defined and established method of health services delivery that enhances patient and client interactions. APTA also recognizes the value of advocating for state and federal telehealth policies to reduce cost, disparities, and shortages of care, and to enhance physical therapist practice, education, and research.

    PT Compact
    Through the Physical Therapy Compact, a compact privilege allows the holder to provide physical therapist services in a remote state under the scope of practice of the state where the patient or client is located, whether the practice is in-person or via telehealth. Compact privilege holders should consult the rules and laws for the state in which they seek to provide services to determine the specific telehealth requirements.

    Payer Policy

    Physical therapists are not statutorily authorized providers of telehealth under Original Medicare, and physical therapy services are not on the list of services covered under the Medicare physician fee schedule when furnished via telehealth. (See the Private Payer section below for information on services provided under Medicare Advantage plans.) APTA has continued to advocate for the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act of 2019 (H.R. 4932/S. 2741), legislation that would expand the use of telehealth services and ease restrictions on telehealth coverage under the Medicare program. Our position paper outlines APTA's stance on the legislation (.pdf). The COVID-19 pandemic makes our position all the more relevant; health care providers and payers must reconsider how care is delivered to reduce the risk of further spreading infection. Access to telehealth has become of paramount importance to ensure the safety of patients and their physical therapy providers. We have developed a template letter you can send to your legislators (.pdf) asking them to cosponsor these bills.

    APTA also has compiled research studies on telehealth (.pdf) and testimonials from APTA members on how they have balanced in-person and telehealth visits.

    Private Payer
    Check with individual payers to verify what is and is not permitted and what will be reimbursed. Confirm with each payer whether the originating site can be a private home or office, if services must be real-time or can be asynchronous, and any other limitations to your use of telehealth. Before reporting CPT codes you traditionally use for clinical visits, check with your payer. A payer also may require an addendum attached to the bill that identifies the service as being provided via telehealth, along with an explanation of the charges, so be prepared to outline your reasoning for using telehealth. Also be aware if your state has parity laws that require insurers to pay the same amount for telehealth services as they would for an in-person visit.

    Note: Under CMS guidance issued to Medicare Advantage organizations (.pdf), CMS is affording MAOs the flexibility to expand coverage of telehealth services.

    APTA developed a template letter for you to use in advocating to your payers--private, Medicare Advantage, and Medicaid (both fee for service and MCOs) for coverage of telehealth furnished by PTs and PTAs to ensure that patients continue to have access to the rehabilitative care they need amid the COVID-19 pandemic. Instructions are included at the top of the page.

    States have the option to determine whether or not to cover telehealth services; what types of telehealth services to cover; where in the state such services can be covered; how services are provided and covered; which types of providers may be reimbursed for telehealth services (as long as they are "recognized" and qualified according to the state's Medicaid statute or regulation); and how much to reimburse for telehealth services, as long as payment does not exceed federal upper limits.

    Medicaid guidelines require all providers to practice within the scope of their state practice act. Some states' legislation requires providers using telehealth technology across state lines to have a valid state license in the state where the patient is located, and these requirements are binding under current Medicaid rules.

    Before you bill for telehealth services under Medicare, always check the regulations and policies of your state Medicaid fee-for-service (FFS) program and Medicaid managed care organizations to confirm whether or not the FFS program and/or MCOs reimburse for telemedicine services.

    The Center for Connected Healthcare Policy identified the following in a 2019 summary of state telehealth policies, including telerehabilitation:

    • 9 states (Arkansas, Connecticut, Delaware, Idaho, Kentucky, Minnesota, Missouri, New York and Oregon) explicitly reimburse for telerehab services.
    • 11 states (Iowa, Maine, Montana, Nebraska, New Mexico, North Dakota, Rhode Island, Tennessee, Utah, Vermont and Washington) contain open language in state regulation or reimbursement policies that may allow for Medicaid to reimburse for telerehab services.

    Medicaid policies on the originating site setting (private home or office) and real-time vs. asynchronous services also differ among states, so check your state's policy as well as each payer's policy.

    The Center for Connected Healthcare Policy has a good resource that identifies where the law stands with telehealth in the states (.pdf).

    There are not specific CPT codes for telehealth services furnished by physical therapists. Some therapists use codes in the 97000 series that best describe the services being provided and then use the place-of-service code "02" to indicate that the services were provided remotely. Because the CPT codes are direct contact codes it is important to verify that the payer allows you to use these codes when services are provided via telehealth, or if you must use a specific modifier. We also encourage you to check with each payer about using place-of-service code "02" when billing for telehealth services to specify the entity where service(s) were rendered.

    Learn More
    In addition to the links to resources above, we will continue to develop education related to delivery of services via telehealth. For one thing, APTA staff will prerecord a webinar in early April with members of the Health Policy and Administration Section's Tech SIG. The webinar, Digital Telehealth Practice - Connect for Best Practice, Compliance, and Healthcare, will then be followed by a live online Q&A session later in the month.

    These resources should answer most of your questions on billing and coding, practice considerations, legislation and regulation, and other issues related to telehealth. If you still have a question that wasn't addressed, send it to advocacy@apta.org. We will update our resources accordingly to ensure we're providing the information the profession needs.